“I Know So Many Women That Have the Same Story as Mine”: Exploring How the Increase of Benzodiazepines in the Unregulated Drug Supply Shapes Experiences of Gender-Based Violence Among Women and Gender Minorities in Vancouver,BC

Structural, Symbolic, and Everyday Violence and Experiences of WWUD

GBV refers to the harmful acts directed at a person or persons based on their gender identity, gender expression, or perceived gender, and can manifest as physical, sexual, emotional, and/or psychological violence (Walsh et al., 2015). Intersecting modes of economic and social marginalization, criminalization, racist, settler colonial logics, and drug war violence shape WWUDs’ experiences of GBV, with factors such as heightened surveillance and interactions with police—who are often also perpetrators of GBV—further increasing WWUDs′ exposure to GBV (Birgin et al., 2022; Boyd et al., 2018; Collins et al., 2020a; Collins et al., 2020b; Gilbert et al., 2015; Goldenberg, 2020; Harris et al., 2024; Knight et al., 2014; Ohtsuka et al., 2023; Shannon et al., 2008). Trans and two-spirit people face GBV at heightened rates due to the added layers of gendered discrimination and exclusion embedded within many facets of our societal fabric (Martin & Walia, 2019).

Concepts of structural, symbolic, and everyday violence are useful in examining WWUDs’ experiences of GBV. Structural violence refers to how social structures and institutions sustain, perpetuate, and routinize inequalities and resulting harms. Analyses applying this lens have highlighted how macrocontexts (e.g., drug prohibition, gender subordination, racism, systemic social exclusion, economic marginalization, etc.) have an impact on microcontexts (e.g., WWUDs’ individual drug use experiences), shaping the health and safety of WWUD, including their exposure to GBV (Boyd et al., 2022; Farmer, 2009; Galtung, 1969; McNeil et al., 2014; Scheper-Hughes & Bourgois, 2004; Shirley-Beavan et al., 2020).

Internalization of social–structural subordination because of its ubiquity and resulting self-blame is understood as symbolic violence (Bourdieu, 1979). Structural and symbolic violence commonly presents itself as a form of everyday violence, a term that refers to the normalization of violence that is often embedded within gendered relations and rendered invisible due to its pervasiveness (Bourdieu, 1979; Scheper-Hughes & Bourgois, 2004). Such experiences of everyday violence in the lives of WWUD have been highlighted in past works, underscoring how gendered power dynamics are regularly expressed through violence and often inflicted by police, intimate partners, or unknown people in community, and compounded by criminalization (Boyd et al., 2018; Collins et al., 2020a; McNeil et al., 2014).

GBV among WWUD is an urgent public health concern given its prevalence and normalization, and direct association with drug war violence. Experiences of GBV in the context of the unregulated drug toxicity crisis have been shown to increase the likelihood of overdose for WWUD (Ataiants et al., 2022; Collins et al., 2020a; Gilbert et al., 2022; Goldenberg, 2020; Knight, 2017). As already alluded to, ongoing systems of settler colonialism, as well as the racist and imperialist logic in which prohibition was founded, has meant that this link is especially pronounced for Indigenous or otherwise racialized WWUD (Gordon, 2006; Lavalley et al., 2018). Indigenous women in Canada experience physical violence at 8 times the rate as non-Indigenous women, while also making up 36% of BC's fatal overdoses in 2022—a rate 8.8 times higher than non-Indigenous women (First Nations Health Authority, 2022; Martin & Walia, 2019; Thumath et al., 2021). Notably, Indigenous women and two-spirit people have repeatedly attempted to raise the alarm on the disproportionate levels of GBV they face within Canada, combatting the normalization of this reality (Martin & Walia, 2019).

WWUD have also reported gendered barriers to accessing harm reduction services, including overdose prevention sites. These are spaces that are both regularly surveilled by police and dominated by men, with some WWUD experiencing exclusion, intimidation, and harassment while accessing these sites, including being confronted by police and/or violent actors in community who they have been previously victimized by (Boyd et al., 2018, Collins et al., 2020b). This has resulted in many WWUD voicing concerns regarding safety and the threat of GBV in and beyond such service delivery settings, reducing the likelihood of WWUD utlizing these sites (Austin et al., 2023; Boyd et al., 2018; Collins et al., 2020b; Harris et al., 2024; Martin & Walia, 2019; Shirley-Beavan et al., 2020; Värmå Falk et al., 2020).

While past research has drawn important connections between drug prohibition, gender, and experiences of violence, what remains underexplored is the various impacts that the influx of benzodiazepines in the increasingly volatile unregulated drug supply have on WWUD. Focusing on WWUD who experience intersecting modes of criminalization, our analysis incorporates concepts of structural, symbolic, and everyday violence to evaluate the ways in which which the surge of benzodiazepines in the supply has shaped the health, safety, and experiences of GBV among WWUD in Vancouver, BC.

Prohibition as a Form of Structural Violence: The Influx of Benzodiazepines in the Unregulated Drug Supply and Everyday Experiences of Violence Among WWUD

Participants repeatedly underscored the ways in which prohibitionist policies and the subsequent unpredictability of the unregulated drug supply made it exceedingly difficult to discern drug content, negatively affecting WWUDs’ everyday lives. In particular, participants discussed situations in which they were uncertain about what type of substance they were buying, leading some to purchase benzodiazepines or “benzodope” (e.g., benzodiazepines mixed with opioids) when intending to buy, for example, opioids such as fentanyl. The evolution of the supply was described by one participant who stated: “Well, it's going from fentanyl to carfentanyl to benzos, and shit has just been so bad” (Participant 11).

The sudden influx of benzodiazepines in the unregulated drug supply following the COVID-19 pandemic, combined with low benzodiazepine tolerance or familiarity, meant that WWUD were often unprepared to deal with the effects of benzodiazepines, exacerbating the potential for being targeted by violent actors, including strangers, supposed friends, or intimate partners.

The word benzo isn’t something that we used very often. It was like, okay what is that? Oh okay, they’re like valium? I didn’t realize they were a big thing […] And now it's like it's this dark word, ‘do you have benzodope or do you have non-benzo [dope]? Are you [dealer] gonna lie about it or not? Because if you do, then my days gonna be sabotaged and I don’t know if I’m gonna have a home, if I’m gonna get robbed. You can lose everything in a day and I see it happen to people. Like, they’re getting beaten, robbed, by their friends, or their supposed friends. It's really scary. (Participant 03)

In the absence of regulatory controls to minimize the far-reaching effects of prohibition and the resulting uncertainty about drug content, WWUD remained susceptible to unwanted benzodiazepine exposure. As outlined by this participant, using benzodiazepines unknowingly can heighten WWUDs’ experiences of physical or sexual assault, or place WWUD in a position where they could “lose everything” due to the exploitative practices of some who weaponize the broader violence of the drug war to their own benefit. The significant social and structural violence endured by many WWUD—shaped by forces such as criminalization, settler colonialism, racism, social exclusion, and gendered surbodination—was described as further exposing WWUD to GBV, theft, and exploitation, perpetuating and normalizing the everyday violence WWUD are confronted with. Notably, as highlighted by the above quote, such experiences had the potential to be profoundly destabilizing for WWUD, particularly those who were living in poverty.

While some participants described unintentionally using benzodiazepines as a result of the volatile supply, many purposefully sought out benzodiazepines due to their myriad positive effects, including reducing anxiety and instilling a sense of calm: “When I take benzos, it makes me feel like everything is OK. They’re kind of like a coping mechanism that I use, honestly […] it's something that's always been helpful” (Participant 25). Despite this, the impacts of prohibition meant that potency was often difficult to determine. Similarly to the discussions around unknown benzodiazepine use, participants spoke to the ways in which the unintended use of high strength benzodiazepines contributed to negative drug use experiences, placing some WWUD in precarious or potentially unsafe positions.

The other day I had a fire right across my hall, and […] my place was clouded with smoke. I ended up doing a shot of benzodope, it was supposed to be very light benzos, and I was down and out and, passed out, for the entire day into the evening. I didn’t realize that there was a fire. [My boyfriend] called my boss and said ‘she can’t go to work, she's benzo’d.’ [I was] talking like totally coherent, but my brain wasn’t there. Like I’m functioning, but my brain isn’t there. (Participant 03)

These narratives illustrate that the fluctuating potency of benzodiazepines in the unregulated drug supply may result in experiences of long lasting memory loss, drowsiness, confusion, or other symptoms that can work to heighten WWUDs’ vulnerability to exploitation in different contexts; this includes altered levels of awareness and heightened exposure to various forms of disappearances (e.g., the disappearance of memory, disappearance from public space in order to avoid violence, etc.). Notably, such experiences of reduced awareness, in tandem with the sedative effects of benzodiazepines, were described as potentially increasing WWUDs’ likelihood of being targeted and violently harmed.

For some participants, episodes of intense benzodiazepine-related memory loss lasted from a few hours to several days, leading to the disappearance of long stretches of time. These experiences compounded the stress and fear many endured after the unknown use of benzodiazepines, or exposure to high potency benzodiazepines, making it increasingly difficult for WWUD to piece together what had happened to them. Given the structural context of pervasive gender inequities and subsequent high rates of GBV among WWUD, this type of long-lasting memory loss was identified as being especially concerning (Boyd et al., 2018). This was described by one participant who stated:

You have no memory [of] what you did for days, two, three or four days, right. And you think, where could I have been for four days? Where was I? What was happening to me? (Participant 21)

Similarly, others discussed waking up with bruises, missing belongings or articles of clothing, or in an unknown location after being tarteged during a prolonged “benzo blackout”. Such experiences further exemplified how unpredictable benzodiazepine use, enabled by prohibition, had the potential to alter perceptions of time and memory, increasing WWUDs’ vulnerability to violence, especially in situations where participants were isolated and/or unable to lean on support networks for safety.

Sub-Theme: The Effects of Prohibition on Sex Workers Who Use Drugs’ Occupational Health and Safety

For sex workers, the volatile drug supply was described as adding an additional layer of complexity, with the potential to negatively shape occupational conditions. Participants especially underscored that using benzodiazepines in unknown or unpredictable quantities often made it difficult to enact critical safety strategies that strengthen sex workers’ occupational health and safety (e.g., screening clients, working in collaboration with others, etc.) amid ongoing criminalization.

One time [after using benzos] I don’t even remember going with this guy. […] I just sorta remember coming back on the train. And I didn’t know what I was doing on the train. And I got off at a station and I had to catch a bus back here [to my home] and I was wondering why I was on the train and I was trying to piece it together. And then my friend said we were doing benzo dope at [X's] place and I decided to go out with this guy that stopped by to pick me up. And I was like holy fuck that's why I was on the train. I did a date. (Participant 01)

As illustrated through the above narratives, the impairment that can be caused after using benzodiazepines unknowingly or at a higher strength than intended can limit the ability for sex workers to adequately control their working conditions or environment, with some reporting having no memory of working at all. This meant that, in a few instances, workers were ripped off or unable to dictate the terms of their transaction (e.g., unsure about where the date took place, if a condom was used, etc.) after using benzodiazepines, increasing vulnerability to occupational violence, including GBV, carried out by predatory people posing as clients. The dangers associated with the memory loss endured by participants in this context were described as being made more complicated by the structural violence sex workers who use drugs face due to their dual criminalization, further limiting access to recourse and undermining safe working conditions, ultimately increasing the likelihood of experiencing more intensified forms of everyday violence and subsequent disappearances (e.g., disappearance from a public space to avoid perpetrators of violence and/or police, more permanent forms of disappearances resulting from physical violence or overdose).

The Normalization of Everyday Experiences of Violence Among WWUDs

Consistent with the previous section, the normalization of WWUDs’ exposure to physical or sexual violence as a result of benzodiazepine-related memory loss was explicitly highlighted by several participants:

Because you’re blacking out and you don’t remember what you’re doing, you seem like you’re fine but you’re not fine. You’re not there. You can be walking around, functioning but no one's home at that time. How could [they] not take advantage of you, right? (Participant 03)

While this participant spoke directly to benzodiazepine use and resulting experiences of memory loss, her narrative points to an even broader concern wherein GBV has become a regular part of some WWUDs’ drug use experiences in the context of systemic gender subordination and misogyny. Given the increasingly unpredictable drug supply, the implication that WWUD will be “taken advantage of” in vulnerable moments demonstrates how the above-mentioned social and structural violence (e.g., gender subordination, settler colonialism, stigma, entrenched poverty, social exclusion, etc.) endured by WWUD, combined with the structural violence reproduced through drug prohibition, shapes both WWUDs’ exposure to GBV and creates the conditions under which GBV is understood as being commonplace. In this way, this participant demonstrates how the normalization of everyday violence among WWUD allows for incrementally more abhorrent forms of GBV (both at the interpersonal and state level) to persist as routinized and justified.

Notably, the normalization of violence among WWUD led some participants to blame themselves for the violence they had experienced. “The effects of doing benzos – I tell you benzos destroy [people] […] Because some of the stuff [that happens]….the worse shit [that happens] the worse shame and remorse you go through, right” (Participant 23). This kind of self-blame, which can also be understood as a form of symbolic violence, in tandem with the intense emotional and physical trauma some experienced in the context of extended benzodiazepine-related memory loss, had a profound impact on WWUDs’ mental health and well-being, perpetuating the cycle of violence endured by WWUD.

Prohibition as a Form of Structural Violence: The Rise of Benzodiazepines in the Unregulated Drug Supply and the Overdose Experiences of WWUD

The fear of being taken advantage of or harmed in the context of benzodiazepine-fueled memory loss, drowsiness, or confusion, meant that many of the participants we spoke to preferred to use alone at home. This experience was described by one participant who stated: “I'm actually safer using alone in my suite, than being somewhere and then passing out and getting all my stuff stolen kind of thing” (Participant 13).

Critically however, this is contradictory to the directives given to never use drugs alone due to the crisis-level risk of overdose fueled by prohibition (Government of British Columbia, 2025). It is important to note that, while such directives do not attend to the structural violence of the unregulated drug toxicity crisis and how it engenders everyday violence—as well as skirt government responsibility in meaningfully addressing the central drivers of the crisis—they remain in place given the nature of the current drug supply. Despite this, many WWUD continued to use alone in order to avoid the potential for GBV, disappearing them from public view and increasing their likelihood of experiencing a fatal overdose.

In a few instances, the preference to use alone was furthered by WWUDs’ limited options for recourse following experiences of violence, including assault or theft. As already noted, participants discussed situations in which predatory people would take advantage of the memory loss experienced by WWUD after benzodiazepine use to target them with relative impunity. Contacting police was not an option for participants, with many noting that the police often perpetuated the GBV that WWUD experienced in these situations. For example, participants described instances where the police caused additional harm by questioning or not believing WWUD, profiling WWUD due to their criminalized identity, arresting WWUD for violating the terms of their probation (including using drugs when directed not to, and/or entering a red zone that the person had been forbidden to enter), or directly inflicting physical, emotional, or psychological violence upon WWUD. Such police interactions represented another form of disappearance experienced by WWUD; not only did many participants feel unable to be in public areas due to the potential risk of violence from people in community, they also wanted to avoid the systemic and targeted violence perpetrated by police towards WWUD.

The inconsistency of drug composition and potency also contributed to participants’exposures to drug toxicity. While many discussed using benzodiazepines with no issue, without the quality control provided by legal regulation benzodiazepines can heighten the risk of complex overdose, especially when combined with opioids (e.g., “benzodope”). This is made more concerning by the fact that naloxone, a medication that can temporarily reverse an opioid overdose, does not work on benzodiazepines. Several participants noted that they had experienced a near fatal overdose within the year prior to our interview.

And I’ll be narcaned like eight times or so so, it scares the hell outta me and it happens to a lot of people out there. They just don’t react well to benzos. Like even the smallest traces. And that's what's killing a lot of people. Your brain forgets to breathe is literally what it is. (Participant 03)

As pointed out by this participant, benzodiazepines, like opioids, can affect the ability of people to breathe properly due to its depressant effects on the central nervous system, increasing the likelihood that an overdose involving benzodiazepines might be fatal. Without the ability to use naloxone as a means of benzodiazepine overdose reversal, overdose responses are generally more involved, with those experiencing a “benzodope” overdose often taking longer to return to baseline. In tandem, participants also described that people sometimes remain unconscious for hours following a “benzodope” overdose, shaping the risk of overdose-related complications.

Notably, participants expressed that WWUD will continue to experience preventable deaths and other forms of violence, including GBV, if the largely prohibition-based status quo remains unchallenged. Government inaction regarding prohibition was seen as a central part of the violence endured by WWUD, normalizing GBV and mass death and making many WWUD feel as though their lives were expendable. In order to curb the negative experiences associated with unknown or unpredictable benzodiazepine use, including overdose, participants repeatedly spoke to the importance of ending prohibition and regulating the unregulated drug market, which would allow WWUD to easily obtain safe, accessible drugs that are similar in composition to street-level drugs.

They need to make [safe supply] more realistic. I would say look at like legalizing drugs and stuff. I know it's not gonna work out ideally quite the way you want it to but like, try putting it out there. Like and at a real fucking level. Not like, not like this little Mickey Mouse thing like, you’re like giving children's Tylenol to [adults]. Let people be adults and, make their own decisions because, when it comes down to it they’re gonna anyways and, they’re gonna find a way, so we need to make it safer. (Participant 03)

Narratives especially highlighted the need for different approaches in terms of regulatory models (including medical and nonmedical models) to ensure accessibility and a meaningful reduction in reliance on the unregulated drug supply. Moreover, as pointed to by the above participant, many underscored that any regulatory model implemented should be inclusive, allowing for WWUD “to make their own decisions” about their drug use (e.g., in terms of drug type, consumption methods, etc.) and use drugs for whatever reason they choose without being policed or pathologized, including the pleasurable, relaxing, and social aspects of drug use.

Community Care and Involvement in the Face of Structural and Everyday Violence

WWUD highlighted that community care and involvement were critical in establishing some protection from the violence associated with prohibition-based policies and the subsequent unpredictable drug supply. Participants pointed to the ways in which community networks and information sharing were integral in responding to potentially disruptive or harmful situations, including the prevalence of benzodiazepines, and helped prevent the various disappearances experienced by WWUD in this context. For example, WWUD recounted informing each other about the detection of misidentified (e.g., opioids containing benzodiazepines) or especially potent drugs, which allowed others to adequately prepare for potential risks or be more discerning in what they were purchasing. This was described by one participant who noted:

Um, well I always try to test my drugs, or buy from the same person that I trust […] My friends will also tell me about the dope that's going around so I can be more careful […] Also doing it at home, that's pretty safe for me because there's always someone here. If I'm worried about using certain dope, if I haven't used it before, I will go tell my neighbour to come use with me or check on me. (Participant 26)

Consistent with the above narrative, participants spoke extensively about the ways in which they would look out for each other in order to mitigate the everyday violence and subsequent disappearances perpetuated by the unregulated drug supply. Particularly, WWUD repeatedly described using together in order to avoid the potential for a fatal overdose or being taken advantage of following the unpredictable or unknown use of benzodiazepines.

In line with this, several participants also discussed selling or providing unregulated drugs themselves, disrupting the artificial user/seller binary. Challenging common stereotypes of people who sell drugs, these participants often described engaging in practices of care to ensure drug quality and reduce the potential for prohibition related harms (e.g., unpredictable drug content/quality) for those in their community, particularly other WWUD. This included testing their drugs before selling, acting as a witness or using with others to reduce the potential for fatal overdose, distributing naloxone, and/or supplying people within their networks.

Community-run spaces were also discussed as being hugely important in building connections and contributing to a sense of safety among WWUD in the face of the unsafe conditions largely reproduced by the state, including mechanisms of state surveillance and criminalization. Many participants spoke to such spaces as providing an important refuge from the structural and everyday violence WWUD face.

Well [a local community-run harm reduction site] has a lot of respect from the people on the streets, right? Because they could relate to us and we’re mostly all friends, right? […] So it's a place where I feel safe. (Participant 09)

Participants pointed to the ways that community-run harm reduction organizations are imperative in creating safer spaces for WWUD to manage the intersecting impacts of the ongoing unregulated drug toxicity crisis. Beyond mitigating the risk of a potentially fatal overdose, such spaces also ensure protection from the GBV associated with unpredictable or high potency benzodiazepine use in community. For WWUD, these spaces were also discussed as ensuring reliable community support and relative protection from police or related modes of state violence.